Healthcare Provider Details

I. General information

NPI: 1992163034
Provider Name (Legal Business Name): CARLOS A GRANADOS QUINTANILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23824 HAWTHORNE BLVD STE 200
TORRANCE CA
90505-5935
US

IV. Provider business mailing address

43713 20TH ST W STE 2
LANCASTER CA
93534-4628
US

V. Phone/Fax

Practice location:
  • Phone: 310-791-3064
  • Fax: 310-791-3084
Mailing address:
  • Phone: 818-221-8218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number101795
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number84644
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: